Bowling Supplemental Application

Transcription

1 Brown & Brown of South Carolina, Inc. 10 Falcon Crest Drive, Suite 100 Greenville, South Carolina (864) or Fax (864) Bowling Supplemental Application Insured s Legal Name: Entity Type: Sole Proprietor Partnership Corporation Other Location Address: City: County State: Zip: Mailing Address (If different): Phone: Fax: Business Tax ID Number: Web Site: Annual Gross Revenues: PAST 12 Months NEXT 12 Months Bowling (including Shoe Rental) $ $ Restaurant/Snack Bar $ $ Pro Shop $ $ Arcade $ $ Liquor $ $ Vending $ $ Other Please Describe $ $ $ $ $ $ Annual Payroll: PAST 12 Months NEXT 12 Months Bowling $ $ Restaurant $ $ Other Please Describe $ $ Other Please Describe $ $ 1

2 BOWLING ACTIVITIES 1. Total Years in Business: At This Location: 2. Hours of Operation: Sun: Mon-Thur: Fri-Sat: 3. Total Number of employees? Full Time: Part Time: 4. Number of Lanes: 5. Do you contract lane refinishing? Yes No 6. Lane Construction: Wood Synthetic 7. Lane Finish: Lacquer Polyurethane (if flammable, need Product Code ) Urethane (if flammable, need Product Code ) Water Based 8. Are ball racks secured and anchored to the floor? Yes No 9. Does your bowling center have automatic Scoring equipment? Yes No 10. Are any flammable liquids stored on premises? Yes No If yes, list products & quantities: 11. Are all flammable liquids stored in UL approved containers? Yes No 12. Percentage of business from: League Activity Open Play 13. Distance to coastal body of water: (specify # of miles or feet) 14. Do you sponsor any professional tournaments? Yes No If yes, list events and sponsoring organization: If yes, are certificates of insurance obtained? Yes No 15. Do you have a pro shop on premises? Yes No Is your pro shop: Employee Independent Contractor If an Independent Contractor, is insurance placed elsewhere? Yes No If leased to a third party, please provide the square footage: (Certificate of Insurance is required) OTHER RECREATIONAL ACTIVITIES 16. Does your bowling center have amusement devices? Yes No If yes, indicate number of each: Electronic Games Pool Tables Pinball Machines Mechanical Bulls Dart Machines Gaming Machines Other (Describe) Leased or Owned: 17. If the bowling center has dart boards, are they isolated from the other patrons? Yes No 18. Do you lease your facility for birthday parties or banquets? Yes No Please describe the type of Banquets? 19. Do you provide child care services? Yes No If yes, what is the maximum number of children at any one time? 20. What is the ratio of adults to children? 21. What is the minimum age of childcare staff? 2

3 OTHER RECREATIONAL ACTIVITIES (CONTINUED) 22. What is the minimum age of children? 23. Do you perform background checks on your adult staff, whether volunteers or paid employees? Yes No 24. Any other activities or business operations? Yes No Please Describe: RESTAURANT / SNACK BAR EXPOSURE 25. Please check all that apply: Snack Bar Restaurant Bar Banquet Hall 26. Is the restaurant leased to a third party? Yes No If yes, provide the square footage of the restaurant/snack bar: (Certificate of insurance is required) 27. Are all cooking surfaces protected by a hood and duct system? Yes No 28. Do you have a service contract with a contractor to clean the hood and ductsystem? Yes No 29. Is there an automatic extinguishing system? Yes No 30. What type of automatic extinguishing system is in place? UL300: Wet Dry 31. How often is the system serviced and maintained? Monthly Quarterly Semi-Annual Annual 32. When the system was last inspected and serviced? 33. Do you have a deep fat fryer on premises? Yes No 34. Are portable fire extinguishers provided in the kitchen? Yes No Last Service Date: 35. Are food and beverages permitted in the bowling area Yes No BUILDING INFORMATION 36. Year Constructed: If over 20 years old, please provide date and description of last update to: Electric: Heating: Plumbing: Roof: 37. Roof type (flat, bowstring truss, etc): If bowstring truss, date of last inspection: (Attach copy of engineering report) 38. If bowstring truss, is the construction: Wood Steel 39. Building Construction: Block Metal Frame Other 40. Building Area in Square Feet: 3

4 BUILDING INFORMATION (CONTINUED) 41. Is building protected by a sprinkler system? Yes No 42. Does the bowling center have any alarm systems? Yes No If yes, what type: Smoke/Heat Burglary Fire Name of alarm monitoring service: 43. Parking Lot: Paved Gravel Dirt Lighted Other: 44. Security Cameras? Yes No 45. Who is your responding Fire Department? Miles to Station: Number of feet from Hydrant: 46. Which of the following does the Center use to minimize damage from lightning: Overload Circuit Breakers In-Line Lightning Resistors Surge Protectors Ground Fault Circuit Interrupters Other: NON-OWNED / HIRED AUTOMOBILE COVERAGE 47. Do you have a business auto policy for owned autos? Yes No 48. Do employees/volunteers use their autos for company business? Yes No 49. Do you make sure that employees/volunteers that use their personal auto for company business have personal auto insurance per your states minimum requirements? Yes No BAR / LOUNGE / BANQUET EXPOSURE 50. If you have more than one operation at the same location, provide breakdown of receipts by operation: Bar/ Lounge $ $ $ Restaurant $ $ $ Banquet Hall $ $ $ Retail Sales $ $ $ Other $ $ $ 51. Liquor License name: 52. Liquor License Number: Class of License: 53. Has your alcoholic beverage license been revoked or suspended? Yes No If yes, explain: 54. Have you had any occurrences that have arisen out of the sale of any alcoholic beverage? Yes No 55. Has your liquor liability insurance been canceled or non-renewed in the last 3 years? Yes No If yes, explain: 56. Have you ever been fined by alcoholic beverage control or other governmental regulator? Yes No If yes, explain: 57. Have you ever filed for Bankruptcy? Yes No If yes, explain: 4

5 BAR / LOUNGE / BANQUET EXPOSURE (CONTINUED) 58. Type of alcoholic beverages sold: What proof? 59. Are patrons allowed to bring their own alcohol? Yes No If yes, what type? 60. Number of servers used: 61. Professional (2 years bartender experience or more) Yes No 62. Non-Professional (no bartender experience) Yes No Explain: 63. Are all alcohol-serving employees certified in a formal alcohol training course? Yes No If yes, provide name of course: TIPS TAM RAMP BEST OTHER: 64. At what location are IDs checked and how often? 65. In what size container are alcoholic beverages served? Glass/Cup oz. Pitcher oz. Other: 66. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No Explain: 67. Do you serve beer or alcohol from bar carts? Yes No 68. Hours of operation for the bar / lounge: Monday through Thursday Saturday Friday Sunday 69. Is there a separate outside entrance to the bar or Lounge Area? Yes No 70. Does bowling center feature any entertainment? Yes No How often? 71. Type of entertainment featured: DJ Jukebox Karaoke Solo Vocalist Band (1-3 members) Band (4+ members) Other: 72. If musical entertainment, what type? Top 40 s / Pop Classic Rock Soft Rock Alternative Country Jazz R&B Rap Other: 73. Is dancing permitted? Yes No 74. Is there a dance floor? Yes No If yes, size of dance floor: Sq. ft. 75. Is there a minimum or cover charge? Yes No 76. Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No 77. Is there any type of designated driver program in effect? Yes No 78. Describe security measures in place: Number of uniformed police officers present at the site of alcohol sales: Number of undercover police officers present: Number of private security present: Other: 5

6 BAR / LOUNGE / BANQUET EXPOSURE (CONTINUED) 79. Are rules and regulations clearly displayed for patrons viewing? Yes No Explain: 80. Other promotional activities or events? 81. Type of clientele: Area Residents Area Workers Tourists College Other: 82. Average age of patrons: Percentage of clientele: Under Over Is an Additional Insured needed? Name: Address: Describe Interest: 6

7 CURRENT COVERAGE **This information is not required, however, this information will help us to better analyze your account needs and will also help us to obtain the most competitive quote! Property: Current Property Carrier: Annual Premium: $ Current Building Coverage: $ Current Contents Coverage: $ Do you have coverage for: Equipment Breakdown $ Signs $ Wind & Hail Deductible $ or % 100% Value of Bowling Lanes and Bowling Equipment: $ Bowling Lanes and Equipment to be covered: Replacement Cost ACV Bowling Lanes and Equipment Values are included in: Building Value Contents Value Business Income Limit: General Liability: Current General Liability Carrier: Annual Premium: $ Current Limits of Liability: $ Liquor Liability: Current Liquor Carrier: Annual Premium: $ Current Limits of Liquor Liability: $ Workers Compensation: Current Workers Compensation Carrier: Annual Premium: $ States Covered: Current Employers Liability Limits: Bodily Injury by Accident/Each Accident: $500,000/$500,000 $1,000,000/$1,000,000 Bodily Injury by Disease/Each Employee: $500,000/$500,000 $1,000,000/$1,000,000 Workers Compensation Experience Modifier (if known): ** Send us a copy of your current policies, loss runs, and a copy of your experience modifier and we will do a full analysis of your coverage** 7

8 Applicant s Statement and Declarations The applicant declares to the best of his / her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein. Signature of Applicant Title Date Signature of Producer Date 8

9 Disclaimers NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME. NOTICE TO MINNESOTA AND OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO NEBRASKA AND OKLAHOMA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO NEW JERSEY APPLICATIONS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON A N APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO MAINE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. NOTICE TO TENNESSEE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. 9